Traumatic hyphema: causes, symptoms, diagnosis, treatment

Hyphema - the presence of blood in the anterior chamber. The amount of blood can be microscopic (microhyphema), when red blood cells in watery moisture are visible only with biomicroscopy, or the blood is located in the anterior chamber.

With total hyphema, the blood fills the entire anterior chamber. The total hyphema with coagulated blood turns black, it is called an eight-point one. Traumatic hyphema is associated with blunt or penetrating injury of the eye. In most cases, the hyphema gradually dissolves on its own without any consequences, but there may be repeated bleeding, increased intraocular pressure, and staining the cornea with blood.

Epidemiology of Traumatic Hyphema

Traumatic hyphema appears with blunt or penetrating trauma. Traumatic hyphema is characteristic for young active men, the ratio of the frequency of its appearance in men and women is approximately three to one. The risk of complications, such as repeated bleeding, uncontrolled rising of intraocular pressure or staining of the cornea with blood, increases with increasing size of the hyphema. The only exception is patients with sickle-celled hemoglobinopathies. Such patients are in the group at increased risk of complications, regardless of the size of the hyphema.

Up to 35% of patients suffer from repeated bleeding. In most cases, repeated bleeding develops within 2-5 days after trauma, usually more massive than the previous hyphema, with a greater tendency to develop complications.

[1], [2], [3], [4], [5], [6]

Pathophysiology of traumatic hyphema

Compression forces with blunt trauma tear the iris and vessels of the ciliary body. Tears of the ciliary body lead to damage to the large arterial circle of the iris. With penetrating wounds, there is a direct damage to the blood vessels. Clots of curled blood clog the damaged vessels. Repeated bleeding develops during retraction and lysis of these clots. Intraocular pressure sharply increases in the block of the trabecular network by erythrocytes, inflammatory cells and other organic substances. In addition, intraocular pressure rises with a pupil block, a blood clot in the anterior chamber, or a mechanical blockage of the trabecular network. This form of pupillary block often occurs with eight-point hyphema - total curled hyphema, preventing the circulation of intraocular fluid. Violation of the circulation of aqueous humor leads to a decrease in the oxygen concentration in the anterior chamber and the blackening of the clot.

In patients with sickle cell disease and other features in the formation of sickle cells, erythrocytes become rigid and easily get stuck in the trabecular network, increasing intraocular pressure even with small sizes of the hyphema. In microvascular disorders, patients may experience vessel occlusion and damage to the optic nerve disk at low values of intraocular pressure.

Symptoms of traumatic hyphema

Patients with an anamnesis have a trauma. Careful inquiry about the time and mechanism of injury is very important for assessing the likelihood of additional damage and the need for in-depth examination and treatment. The disease in patients can be asymptomatic, it is possible to reduce visual acuity, the appearance of photophobia and pain. Increased intraocular pressure is sometimes accompanied by nausea and vomiting. There may be signs of trauma to the orbit or damage to other eye tissues.

Diagnosis of traumatic hyphema

Biomicroscopy

When examining with a slit lamp, red blood cells circulating in the anterior chamber are detected, sometimes a hyphema. Symptoms of trauma in other structures of the eye are possible, for example, cataracts, fakodenes, subconjunctival hemorrhage, foreign bodies, wounds, ruptures of the sphincter of the iris or ruptures in the root of the iris (iridodialysis).

Gonioscopy

Gonioscopy should be performed after the risk of rebleeding has disappeared. Over time, from 3 to 4 weeks after the injury, the angle may be undamaged or, which happens more often, detect a recession angle. Cycodialysis is possible.

Rear Pole

At the back pole you can see signs of blunt or penetrating injury. Possible shaking of the retina, ruptures of choroida, retinal detachment, intraocular foreign bodies or hemorrhage into the vitreous. A study with a scleral depression should be postponed until the risk of recurrent bleeding disappears.

Special tests

Ultrasound B-scan should be performed for each patient in the absence of a study of the posterior pole. If a clinical examination reveals a fracture of the orbit or an intraocular foreign body, the patient is sent to a computer tomography of the orbit.

Every black or Hispanic patient, as well as patients with a complicated family history, must take a blood test or conduct hemoglobin electrophoresis on the definition of sickle-cell anemia.

[7], [8], [9], [10], [11], [12]

Treatment of traumatic hyphemaemia

The affected eye is closed with a bandage, the patient is placed on the bed in a position with a raised head. It is necessary to avoid the use of acetylsalicylic acid, non-steroidal anti-inflammatory drugs; use local cycloplegics and glucocorticoids. To prevent repeated bleeding, the patient takes (inside) aminocaproic acid preparations and antifibrinolytic drugs. Aminocaproic acid can cause postural hypotension, nausea and vomiting, so its use in pregnancy and patients with cardiac, hepatological or renal diseases should be avoided. With increased intraocular pressure, topical beta-blockers, a-adrenoagonists or inhibitors of carbonic anhydrase are prescribed locally. Myotics can cause inflammation - they can not be prescribed. In addition, intravenous or intravenous carbonic anhydrase inhibitors are prescribed, except for patients with sickle-celled hemoglobinopathies, since they increase the pH of the intraocular fluid, increasing the formation of sickle-shaped hemoglobin. Such patients should be very careful to appoint hyperosmotic drugs, since an increase in the viscosity of the blood leads to an increase in the concentration of the pathological form of hemoglobin.

Patients with extensive non-absorbable hyphema and early corneal imbibition of blood, as well as in cases of uncontrolled intraocular pressure, are indicated for surgical intervention. The time for the operation to monitor the intraocular pressure is individual and depends on the patient. Surgical intervention is necessary for patients with a normal optic nerve disk with an intraocular pressure of 50 mm Hg. For 5 days or more 35 mm Hg. Within 7 days. Patients with a modified optic disc, corneal endothelial pathology, sickle cell hemoglobinopathy, or its signs need an earlier operation. In addition, surgery is indicated for patients with sickle-cell anemia with intraocular pressure greater than 24 mm Hg. And lasting more than 24 hours.

Surgical manipulations to remove the hyphema include rinsing the anterior chamber, squeezing out a blood clot through the incision in the limb region or removing it by instruments for anterior vitrectomy. To prevent rebleeding, removal of the blood clot is carried out between 4 and 7 days after injury. In most cases, a gentle filtering operation is usually performed to control the intraocular pressure.